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UJ/1V/ZVU8 WED 9:35 FAX 651639 4032 Gambling Control, Bd
<br />Minnesota Lawful Giam�bling
<br />Can I (LG2,010R) Lawful Gambling License Renewal Application
<br />tmm��11 Corrections ShOuld be Made direcdy, on this appli,cation
<br />Submk one check for all renewal fee OR - 411P
<br />5f payable to Slhiltp- Of "ill _r"al-m
<br />OrganizatIon requirements:
<br />1. An iain�nmal OrWilatlOn license fee of $350 is required.
<br />Authorization #,& 330
<br />OrgainIzation- BI-Dale Clu�b
<br />2100 N Dale St. Roseville, mN. 55113
<br />4-N Or
<br />11WE a 'All M JPA
<br />or - AM
<br />Treasut*r,a. P -7
<br />Gambiling Manager Requfre -__
<br />i ents:
<br />1 A I n annum gambling manager license fee Of $100 is required.
<br />rl II
<br />current license term: 4/1/2006 to 3/31/2008
<br />Renewing license term: 4fl/2008 to-3731/2010
<br />GaI.mbling!, I Man�ager AuMDrina tion :. SM-00330-1)()(i Current LiMns e Term: 4/1/2006 to 3/31/2008'
<br />Gtori;; Anr% tciriczm Renewing ficense term-, 4A/2008 to 3/31/2010
<br />indmdua) listed is not renewing heir ffcen-se- We have enclosed a LU,212
<br />applicabon for the new appl-rcant.,
<br />Notes The gambling manager- auties may not be aSsunled by an
<br />individual until they Sr e licensed by ft minnesota
<br />GambliN Control Board.
<br />.OPP
<br />Gambling- Manager A davIt and I Consent statement 0�03
<br />I - I have never been con vir
<br />involving gamblinig, I -ted �of a felony or a crime
<br />2. 1 have never, CoMmitted a,. �viollatioin, Of law or Board rule
<br />that resulted in the revocation, of a licer)se issued by the
<br />ard within five years before the date of the license
<br />application.
<br />3, 1. have never been convicted of a criminal violatlon
<br />Involving fraUd, theft,, tax ev6siont misrepresentation,, or
<br />gambling.
<br />4. 1 Ihav ie never, been convicted of (i) assault, (j4) a criminal
<br />Violation involVing the use of a firiparm
<br />teirTorfstic threats. 1, ()r (iii) making
<br />S. I hive never been,, Or aft' I now connected with or
<br />engaged in an illegal business.
<br />6. 1 have never had, a salles and use tax permit revoked by
<br />the COMMissioner Of rev�enue wMin the past two Years.
<br />7. 1 have never, after dlemand, failed to File tax returns
<br />4
<br />re quired by the CoMmissioner Of revenue.
<br />8. 1 do not owe $500 tor, more in delinquent taxes as defined
<br />i)l !ie�ction 2701.72,
<br />9, 1 have ble.e'n an active Member Of the organization for at
<br />least
<br />-two years at the time Of Our Organization's initial license
<br />application, or have been an active member for at least the
<br />most IreWnt six Months Orior to the effective date of our
<br />Orgiani2ation's license renewal,
<br />10. 1 am not a gambling manager or an assist-ant g llnq
<br />manager for another orgianiizatioln.
<br />I I - I am not a lessair, a member of the lessor's immediate
<br />faMilyr or a person residing in I the same household as the
<br />lessor, or an e1*11PIOYee 01fa (assor of a premises where thi$
<br />organization, has a permit issued frotn, the Board to conduct
<br />Alawfull gambling- I Ct
<br />am
<br />not involved directly or indirectly as a bing ow
<br />mainufacturer. or distributor.
<br />13. 1 am n�ot, the chief exeCutive officer of this 0 tion.
<br />14. X am not the treasurer of this organ ization JAN
<br />IS., I was not an officer of an urganizaWn at a tam erAftft
<br />orfense occurred which caused that organization's I to be&4
<br />revoked.
<br />Baiaq�reund Check, By signature of phis docu men
<br />uniders,ii ned authorizes the Depattments or Public safetyy
<br />9
<br />Revenue to, conduct a criminal and tax background check or re a
<br />Vfew
<br />and to, shlare the results with the Gambling Control Board, Further,
<br />I U Odef5tand, Iagre e,, and hereby irrevocably cons nt that suits and
<br />actions relating to the subject matter of this garnbiing manager
<br />lice�nse apiplica�tion,, or. acts or omissions arising from such
<br />application, May be commenced against Me or my organization and
<br />I Will accent the servlr_e of process in 2ny Court Of competent
<br />jurisdiction tin Minnesota by service oil the Minnesota Secretary of
<br />te of any summons, Process, OF Pleading authorized by the laws
<br />of Minnesota.
<br />Fadure to, Provide required information or providing false or
<br />misleading infQrm4on may result In the denial or revocation of the
<br />license.
<br />Charigez In the information submitted in this awl'ication will be
<br />sUbMitted in writing, no later than 1.0 days after the change. has
<br />taken effe'ct.
<br />111ave read'this application and declare that all information
<br />submitted Is accurate, and complete.
<br />Signature in ink, of gambling
<br />manager applicant
<br />
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